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Congratulations - you have completed FON Practice Exam for Nursing Process, Physical and Health Assessment and Routine Procedures (PM).
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Question 1

In assessing the abdomen, Which of the following is the correct sequence of the physical assessment?

A

Inspection, Palpation, Auscultation, Percussion

B

Inspection, Auscultation, Palpation, Percussion

C

Palpation, Auscultation, Percussion, Inspection

D

Inspection, Auscultation, Percussion, Palpation

Question 2

Which of the following is a OBJECTIVE data?

A

Dizziness

B

Blue nails

C

Chest pain

D

Anxiety

Question 3

She is the first one to coin the term “NURSING PROCESS” She introduced 3 steps of nursing process which are Observation, Ministration and Validation.

A

Hall

B

Nightingale

C

Rogers

D

Johnson

Question 4

Clinitest is used in testing the urine of a client for glucose. Which of the following, If committed by a nurse indicates error?

A

The nurse puts 1 clinitest tablet into a test tube

B

She added 5 drops of urine and 10 drops of water

C

Specimen is collected after meals

D

She added 5 drops of urine and 10 drops of water

Question 5

In cleaning the thermometer after use, The direction of the cleaning to follow Medical Asepsis is :

A

From bulb to bulb

B

From stem to stem

C

From stem to bulb

D

From bulb to stem

Question 6

Nurse Angela diagnosed Mrs. Delgado, who have undergone a BKA. Her diagnosis is SELF ESTEEM DISTURBANCE R/T CHANGE IN BODY IMAGE. Although the client has not yet seen her lost leg, Angela already anticipated the diagnosis. This is what type of Diagnosis?

A

Probable

B

Actual

C

Possible

D

Risk

Question 7

They are the first one to suggest a 4 step nursing process which are : APIE , or assessment, planning, implementation and evaluation.

Yura

Walsh

Roy

Knowles

A

3,4

B

2,3

C

1,2

D

1,3

Question 8

Which of the following is TRUE about respiration?

A

I:E : 4:3

B

I:E 2:1

C

I:E 1:1

D

I:E 1:2

Question 9

John has a fever of 39.5 degrees 2 days ago, But yesterday, he has a normal temperature of 36.5 degrees. Today, his temperature surges to 40 degrees. What type of fever is John having?

A

Relapsing

B

Intermittent

C

Constant

D

Remittent

Question 10

All of the following factors correctly influence respiration except one. Which of the following is incorrect?

A

Hydrocodone decreases RR

B

Increase temperature of the environment, Increase RR

C

Stress increases RR

D

Increase altitude, Increase RR

Question 11

Among the following statements, which should be given the HIGHEST priority?

A

Client is in extreme pain

B

Client’s temperature is 40 deg. Centigrade

C

Client’s blood pressure is 60/40

D

Client is cyanotic

Question 12

Which of the following is a contraindication in taking RECTAL temperature?

A

Very young children

B

NPO

C

Neutropenic

D

Unconscious

Question 13

A characteristic of the nursing process that is essential to promote client satisfaction and progress. The care should also be relevant with the client’s needs.

A

Efficient

B

Organized and Systematic

C

Humanistic

D

Effective

Question 14

Rhina, who has Menieres disease, said that her environment is moving. Which of the following is a valid assessment?

Rhina is giving an objective data

Rhina is giving a subjective data

The source of the data is primary

The source of the data is secondary

A

1,3

B

1,4

C

2,3

D

2.4

Question 15

The primary factor responsible for body heat production is the

A

Muscle activity

B

Release of thyroxin

C

Stress

D

Metabolism

Question 16

Which of the following completely describes PULSUS PARADOXICUS?

A

A greater-than-normal increase in systolic blood pressure with inspiration

B

Pulse is paradoxically low when client is in standing position and high when supine.

C

A greater-than-normal decrease in systolic blood pressure with inspiration

D

Pulse is paradoxically high when client is in standing position and low when supine.

Question 17

Which of the following is a primary factor that affects the BP?

A

Gender

B

Stress

C

Age

D

Obesity

Question 18

When John has been given paracetamol, his fever was brought down dramatically from 40 degrees Celsius to 36.7 degrees in a matter of 10 minutes. The nurse would assess this event as:

A

The goal of reducing john’s fever has been met with full satisfaction of the outcome criteria

B

The desired goal has been partially met

C

The goal has been met but not with the desired outcome criteria

D

The goal is not completely met

Question 19

The American Nurses association formulated an innovation of the Nursing process. Today, how many distinct steps are there in the nursing process?

A

ADPIE – 5

B

APIE – 4

C

ADOPIER – 7

D

ADOPIE – 6

Question 20

Rectal examination is done with a client in what position?

A

Sims position

B

Lithotomy

C

Supine

D

Dorsal recumbent

Question 21

Which of the following is TRUE about the blood pressure determinants?

A

Epinephrine decreases BP

B

Hypervolemia lowers BP

C

Hypervolemia increases GFR

D

HCT of 70% might decrease or increase BP

Question 22

A process of heat loss which involves the transfer of heat from one surface to another is

A

Conduction

B

Radiation

C

Convection

D

Evaporation

Question 23

In palpating the client’s abdomen, Which of the following is the best position for the client to assume?

A

Dorsal recumbent

B

Lithotomy

C

Supine

D

Side lying

Question 24

A community health nurse should be resourceful and meet the needs of the client. A villager ask him, Can you test my urine for glucose? Which of the following technique allows the nurse to test a client’s urine for glucose without the need for intricate instruments.

A

Benedict’s test

B

Litmus paper test

C

Acetic Acid test

D

Nitrazine paper test

Question 25

How long should the Rectal Thermometer be inserted to the clients anus?

A

2 to 3 inches

B

.5 to 1.5 inches

C

1 to 2 inches

D

3 to 5 inches

Question 26

The following are social data about the client except

A

Religious practices

B

Usual health status

C

Family home situation

D

Patient’s lifestyle

Question 27

All of the following are characteristic of the Nursing process except

A

Intrapersonal

B

Cyclical

C

Dynamic

D

Universal

Question 28

Nurse Angela, observe Joel who is very apprehensive over the impending operation. The client is experiencing dyspnea, diaphoresis and asks lots of questions. Angela made a diagnosis of ANXIETY R/T INTRUSIVE PROCEDURE. This is what type of Nursing Diagnosis?

A

Actual

B

Possible

C

Risk

D

Probable

Question 29

In a routine sputum analysis, Which of the following indicates proper nursing action before sputum collection?

A

Tell the client that 4 tablespoon of sputum is needed for each specimen for a routine sputum analysis

B

Secure a clean container

C

Discard the container if the outside becomes contaminated with the sputum

D

Rinse the client’s mouth with Listerine after collection

Question 30

Which of the following is TRUE about temperature?

A

The lowest temperature is usually in the Afternoon, Around 12 P.M

B

Thyroxin decreases body temperature

C

The highest temperature usually occurs later in a day, around 8 P.M to 12 M.N

D

Elderly people are risk for hyperthermia due to the absence of fats, Decreased thermoregulatory control and sedentary lifestyle.

Question 31

Client has undergone Upper GI and Lower GI series. Which type of health assessment framework is used in this situation?

A

Functional health framework

B

Cephalocaudal framework

C

Head to toe framework

D

Body system framework

Question 32

The primary respiratory center

A

Carotid bodies

B

Pons

C

Medulla oblongata

D

Aortic bodies

Question 33

Which of the following is inappropriate in collecting mid stream clean catch urine specimen for urine analysis?

A

Collect early in the morning, First voided specimen

B

Do perineal care before specimen collection

C

Collect 5 to 10 ml for urine

D

Discard the first flow of the urine

Question 34

The heat regulating center is found in the

A

Thalamus

B

Hypothalamus

C

Medulla oblongata

D

Pons

Question 35

Which of the following is incorrect with regards to proper urine testing using Benedict’s Solution?

A

Add 8 to 10 drops of urine

B

If the color remains BLUE, the result is POSITIVE

C

Heat the Benedict’s solution without the urine to check if the solution is contaminated

D

Heat around 5ml of Benedict’s solution together with the urine in a test tube

Question 36

Which of the following need is given a higher priority among others?

A

The client has disturbance in his body image because of the recent operation

B

The client has attempted suicide and safety precaution is needed

C

The client is depressed because her boyfriend left her all alone

D

The client is thirsty and dehydrated

Question 37

When should the client test his blood sugar levels for greater accuracy?

A

During meals

B

In between meals

C

Before meals

D

2 Hours after meals

Question 38

Hyperpyrexia is a condition in which the temperature is greater than

A

39 degree Celsius

B

100 degree Fahrenheit

C

40 degree Celsius

D

105.8 degree Fahrenheit

Question 39

Nurse Angela is about to make a diagnosis but very unsure because the S/S the client is experiencing is not specific with her diagnosis of POWERLESSNESS R/T DIFFICULTY ACCEPTING LOSS OF LOVED ONE. She then focus on gathering data to refute or prove her diagnosis but her plans and interventions are already ongoing for the diagnosis. Which type of Diagnosis is this?

A

Risk

B

Probable

C

Possible

D

Actual

Question 40

How long should the thermometer stay in the Client’s Axilla?

A

4 minutes

B

10 minutes

C

7 minutes

D

3 minutes

Question 41

Which of the following is NOT a contraindication in taking ORAL temperature?

A

Nausea and Vomitting

B

Dyspnea

C

Presence of NGT

D

Quadriplegic

Question 42

When palpating the client’s neck for lymphadenopathy, where should the nurse position himself?

A

In front of a sitting client

B

At the client’s right side

C

At the client’s back

D

At the client’s left side

Question 43

The characteristic fever in Dengue Virus is characterized as:

A

Biphasic

B

Triphasic

C

Bicyclic

D

Tricyclic

Question 44

Which of the following is a correct nursing action when collecting urine specimen from a client with an Indwelling catheter?

A

Insert the syringe straight to the port to allow self sealing of the port

B

Use sterile syringe to aspirate urine specimen from the drainage port

C

Collect urine specimen from the drainage bag

D

Detach catheter from the connecting tube and draw the specimen from the port

Question 45

Which of the following is responsible for deep and prolonged inspiration

A

Medulla oblongata

B

Carotid bodies

C

Aortic bodies

D

Pons

Question 46

Which is a preferable arm for BP taking?

A

The left arm of the client with a CVA affecting the right brain

B

An arm with the most contraptions

C

The left arm

D

The right arm

Question 47

In collecting a routine specimen for fecalysis, Which of the following, if done by a nurse, indicates inadequate knowledge and skills about the procedure?

A

She took around 1 inch of specimen or a teaspoonful

B

Ask the client to call her for the specimen after the client wiped off his anus with a tissue

C

The nurse scoop the specimen specifically at the site with blood and mucus

D

Ask the client to defecate in a bedpan, Secure a sterile container

Question 48

In a 24 hour urine specimen started Friday, 9:00 A.M, which of the following if done by a Nurse indicate a NEED for further procedural debriefing?

A

The nurse ask the client to urinate at 9:00 A.M, Friday and she included the urine in the 24 hour urine specimen

B

The nurse included the Saturday 9:00 A.M urine of the client to the specimen collection

C

The nurse added preservatives as per protocol and refrigerates the specimen

D

The nurse discards the Friday 9:00 A M urine of the client

Question 49

Which of the following is more life threatening?

A

BP = 90/60

B

BP = 80/50

C

BP = 160/120

D

BP = 180/100

Question 50

Dr. Fabian De Las Santas, is about to conduct an ophthalmoscope examination. Which of the following, if done by a nurse, is a Correct preparation before the procedure?

A

Darken the room to provide better illumination

B

Open the windows, curtains and light to allow better illumination

C

Provide the necessary draping to ensure privacy

D

Pour warm water over the ophthalmoscope to ensure comfort

Question 51

How many minute/s is/are allowed to pass before making a re-reading after the first one?

A

15

B

30

C

5

D

1

Question 52

Which of the following is TRUE with regards to Client Goals?

A

They should answer for WHO, WHAT ACTIONS, WHAT CIRCUMSTANCES, HOW WELL and WHEN.

Which characteristic of nursing process is responsible for proper utilization of human resources, time and cost resources?

A

Efficient

B

Effective

C

Humanistic

D

Organized and Systematic

Question 54

Considered as Safest and most non invasive method of temperature taking

A

Rectal

B

Tympanic

C

Axillary

D

Oral

Question 55

When is the best time to collect urine specimen for routine urinalysis and C/S?

A

Before breakfast

B

Midnight

C

Later afternoon

D

Early morning

Question 56

A community health nurse is assessing client’s urine using the Acetic Acid solution. Which of the following, if done by a nurse, indicates lack of correct knowledge with the procedure?

A

The nurse determines abnormal result if she noticed that the test tube becomes cloudy

B

The nurse added the Urine as the 2/3 part of the solution

C

The nurse heats the test tube after adding 1/3 part acetic acid

D

The nurse heats the test tube after adding 2/3 part of Urine

Question 57

Which of the following is INCORRECT in assessing client’s BP?

A

Read the mercury at the upper meniscus, preferably at the eye level to prevent error of parallax

B

Inflate and deflate slowly, 2-3 mmHg at a time

C

The sound heard during taking BP is known as KOROTKOFF sound

D

If the BP is taken on the left leg using the popliteal artery pressure, a BP of 160/80 is normal.

Question 58

If the client is female, and the doctor is a male and the patient is about to undergo a vaginal and cervical examination, why is it necessary to have a female nurse in attendance?

A

To ensure that the doctor performs the procedure safely

B

To assess the client’s response to examination

C

To ensure that the procedure is done in an ethical manner

D

To assist the doctor

Question 59

Measure the leg circumference of a client with bipedal edema is best done in what position?

A

Dorsal recumbent

B

Sitting

C

Standing

D

Supine

Question 60

Which of the following Nursing diagnosis is INCORRECT?

A

Fluid volume deficit R/T Diarrhea

B

Possible ineffective coping R/T Loss of loved one

C

High risk for injury R/T Absence of side rails

D

Self esteem disturbance R/T Effects of surgical removal of the leg

Question 61

A type of heat loss that occurs when the heat is dissipated by air current

A

Evaporation

B

Radiation

C

Convection

D

Conduction

Question 62

The best position for any procedure that involves vaginal and cervical examination is

A

Supine

B

Side lying

C

Lithotomy

D

Dorsal recumbent

Question 63

Which of the following is the correct interpretation of the ERROR OF PARALLAX

A

If the eye level is higher than the level of the meniscus, it will cause a false high reading

B

If the eye level is equal to that of the level of the upper meniscus, the reading is accurate

C

If the eye level is lower than the level of the meniscus, it will cause a false low reading

D

If the eye level is higher than the level of the meniscus, it will cause a false low reading

Question 64

Which of the following statement is true regarding temperature?

A

Oral temperature is more accurate than rectal temperature

B

The bulb used in Rectal temperature reading is pear shaped or round

C

When the client is swimming, BMR Decreases

D

The older the person, the higher his BMR

Question 65

Which of the following nursing intervention is important for a client scheduled to have a Guaiac Test?

A

Encourage caffeine and dark colored foods to produce accurate results

B

Do not eat read meat 12 hours before procedure

C

Continue iron preparation to prevent further loss of Iron

D

Avoid turnips, radish and horseradish 3 days before procedure

Question 66

In palpating the client’s breast, Which of the following position is necessary for the patient to assume before the start of the procedure?

A

Sitting

B

Dorsal recumbent

C

Supine

D

Lithotomy

Question 67

How many minutes are allowed to pass if the client had engaged in strenuous activities, smoked or ingested caffeine before taking his/her BP?

A

30

B

15

C

5

D

10

Question 68

Contains the pneumotaxic and the apneutic centers

A

Carotid bodies

B

Aortic bodies

C

Pons

D

Medulla oblongata

Question 69

Which of the following is TRUE about the auscultation of blood pressure?

A

Pulse +1 is considered as NORMAL

B

Pulse + 4 is considered as FULL

C

The bell of the stethoscope is use in auscultating BP

D

Sound produced by BP is considered as HIGH frequency sound

Question 70

Which of the following is true about the NURSING CARE PLAN?

A

Verbal

B

It is nursing centered

C

Rationales are supported by interventions

D

At least 2 goals are needed for every nursing diagnosis

Question 71

Which of the following is a NOT a correct statement of an Outcome criteria?

A

Discusses fears and concerns regarding the surgical procedure

B

Ambulates 30 feet with a cane before discharge

C

Demonstrates proper coughing and breathing technique after a teaching session

D

Reestablishes a normal pattern of elimination

Question 72

In assessing the client’s chest, which position best show chest expansion as well as its movements?

A

Sitting

B

Prone

C

Supine

D

Sidelying

Question 73

Refers to the pressure when the ventricles are at rest

A

Diastole

B

Pulse pressure

C

Systole

D

Preload

Question 74

Nurse Angela knew that Stephen Lee Mu Chin, has just undergone an operation with an incision near the diaphragm. She knew that this will contribute to some complications later on. She then should develop what type of Nursing diagnosis?

A

Risk

B

Actual

C

Probable

D

Possible

Question 75

Which characteristic of nursing process addresses the INDIVIDUALIZED care a client must receive?

A

Efficient

B

Organized and Systematic

C

Humanistic

D

Effective

Question 76

David, 68 year old male client is scheduled for Serum Lipid analysis. Which of the following health teaching is important to ensure accurate reading?

A

NPO for 12 hours pre procedure

B

Ask the client to drink 1 glass of water 1 hour prior to the procedure

C

Tell the patient to eat fatty meals 3 days prior to the procedure

D

Tell the client that the normal serum lipase level is 50 to 140 U/L

Question 77

Which of the following is TRUE about the mechanism of action of the Aortic and Carotid bodies?

A

If the BP is elevated, the RR increases

B

Low BP leads to Metabolic acidosis

C

Elevated BP leads to Metabolic alkalosis

D

If the BP is elevated, the RR decreases

Question 78

The sequence in examining the quadrants of the abdomen is:

A

RLQ,RUQ,LLQ,LUQ

B

RLQ,RUQ,LUQ,LLQ

C

RUQ,RLQ,LUQ,LLQ

D

RUQ,RLQ,LLQ,LUQ

Question 79

Which of the following statement is TRUE about pulse?

A

Young person have higher pulse than older persons

B

In lying position, Pulse rate is higher

C

Males have higher pulse rate than females after puberty

D

Digitalis has a positive chronotropic effect

Question 80

John has a fever of 38.5 Deg. Celsius. It surges at around 40 Degrees and go back to 38.5 degrees 6 times today in a typical pattern. What kind of fever is John having?

A

Remittent

B

Intermittent

C

Relapsing

D

Constant

Question 81

+++ Positive result after Benedicts test is depicted by what color?

A

Orange

B

Yellow

C

Blue

D

Green

Question 82

Which of the following is among an ideal way of collecting a urine specimen for culture and sensitivity?

A

Collect around 30-50 ml of urine

B

Add preservatives, refrigerate the specimen or add ice according to the agency’s protocol

C

Discard the first flow of urine to ensure that the urine is not contaminated

D

Use a clean container

Question 83

A patient’s chart is what type of data source?

A

Primary

B

Tertiary

C

Secondary

D

Can be A and B

Question 84

In collecting a urine from a catheterized patient, Which of the following statement indicates an accurate performance of the procedure?

A

Clamp below the port for 5 to 10 minutes before drawing the urine from the port

B

Clamp above the port for 30 to 60 minutes before drawing the urine from the port

C

Clamp above the port for 5 to 10 minutes before drawing the urine from the port

D

Clamp below the port for 30 to 60 minutes before drawing the urine from the port

Question 85

The following are correct actions when taking radial pulse except:

A

Put the palms downward

B

Assess the pulse rate, rhythm, volume and bilateral quality

C

Use two or three fingers to palpate the pulse at the inner wrist

D

Use the thumb to palpate the artery

Question 86

Considered as the most accessible and convenient method for temperature taking

A

Rectal

B

Oral

C

Axillary

D

Tympanic

Question 87

Which of the following do not correctly correlates the increase BP of Ms. Aida, a 70 year old diabetic?

A

Disease process like Diabetes increase BP

B

BP is highest in the morning, and lowest during the night

C

Females, after the age 65 tends to have lower BP than males

D

Africans, have a greater risk of hypertension than Caucasian and Asians.

Question 88

A framework for health assessment that evaluates the effects of stressors to the mind, body and environment in relation with the ability of the client to perform ADL.

A

Functional health framework

B

Cephalocaudal framework

C

Body system framework

D

Head to toe framework

Question 89

Which of the following is responsible for the rhythm and quality of breathing?

A

Carotid bodies

B

Pons

C

Medulla oblongata

D

Aortic bodies

Question 90

John’s temperature 10 hours ago is a normal 36.5 degrees. 4 hours ago, He has a fever with a temperature of 38.9 Degrees. Right now, his temperature is back to normal. Which of the following best describe the fever john is having?

A

Relapsing

B

Intermittent

C

Remittent

D

Constant

Question 91

What can you expect from Marianne, who is currently at the ONSET stage of fever?

A

Hot, flushed skin

B

Convulsion

C

Increase thirst

D

Pale,cold skin

Question 92

Who collects Blood specimen?

A

Medical technologist

B

Physician

C

The nurse

D

Physical therapist

Question 93

Too narrow cuff will cause what change in the Client’s BP?

A

False low reading

B

False high reading

C

True high reading

D

True low reading

Question 94

Marianne is now at the Defervescence stage of the fever, which of the following is expected?

A

Goose flesh

B

Sweating

C

Cyanotic nail beds

D

Delirium

Question 95

When does the heart receives blood from the coronary artery?

A

When the valves closes

B

When the valves opens

C

Systole

D

Diastole

Question 96

The difference between the systolic and diastolic pressure is termed as

A

Pulse pressure

B

Pulse deficit

C

Apical rate

D

Cardiac rate

Question 97

Tympanic temperature is taken from John, A client who was brought recently into the ER due to frequent barking cough. The temperature reads 37.9 Degrees Celsius. As a nurse, you conclude that this temperature is

A

High

B

At the low end of the normal range

C

Low

D

At the high end of the normal range

Question 98

Which of the following is the best position for the client to assume if the back is to be examined by the nurse?

A

Standing

B

Prone

C

Sitting

D

Side lying

Question 99

This specimen is required to assess glucose levels and for the presence of albumin the the urine

A

Second voided urine

B

Postprandial urine collection

C

24 hours urine collection

D

Midstream clean catch urine

Question 100

In inspecting the abdomen, which of the following is NOT DONE?

A

The knees and legs are externally rotated

B

Knees and legs are straighten to relax the abdomen

C

Ask the client to void first

D

The best position in assessing the abdomen is Dorsal recumbent

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Congratulations - you have completed FON Practice Exam for Nursing Process, Physical and Health Assessment and Routine Procedures (EM).
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%

Your answers are highlighted below.

Question 1

How many minute/s is/are allowed to pass before making a re-reading after the first one?

A

1

B

30

C

15

D

5

Question 2

In collecting a urine from a catheterized patient, Which of the following statement indicates an accurate performance of the procedure?

A

Clamp below the port for 30 to 60 minutes before drawing the urine from the port

B

Clamp above the port for 30 to 60 minutes before drawing the urine from the port

C

Clamp below the port for 5 to 10 minutes before drawing the urine from the port

D

Clamp above the port for 5 to 10 minutes before drawing the urine from the port

Question 3

When is the best time to collect urine specimen for routine urinalysis and C/S?

A

Before breakfast

B

Early morning

C

Later afternoon

D

Midnight

Question 4

Considered as the most accessible and convenient method for temperature taking

A

Oral

B

Rectal

C

Axillary

D

Tympanic

Question 5

In palpating the client’s abdomen, Which of the following is the best position for the client to assume?

A

Dorsal recumbent

B

Side lying

C

Supine

D

Lithotomy

Question 6

Which of the following is the best position for the client to assume if the back is to be examined by the nurse?

A

Prone

B

Standing

C

Side lying

D

Sitting

Question 7

+++ Positive result after Benedicts test is depicted by what color?

A

Orange

B

Green

C

Blue

D

Yellow

Question 8

In palpating the client’s breast, Which of the following position is necessary for the patient to assume before the start of the procedure?

A

Dorsal recumbent

B

Supine

C

Lithotomy

D

Sitting

Question 9

Which of the following is TRUE about respiration?

A

I:E 1:1

B

I:E 2:1

C

I:E : 4:3

D

I:E 1:2

Question 10

Which of the following is a OBJECTIVE data?

A

Blue nails

B

Dizziness

C

Chest pain

D

Anxiety

Question 11

The primary respiratory center

A

Carotid bodies

B

Aortic bodies

C

Pons

D

Medulla oblongata

Question 12

In a 24 hour urine specimen started Friday, 9:00 A.M, which of the following if done by a Nurse indicate a NEED for further procedural debriefing?

A

The nurse included the Saturday 9:00 A.M urine of the client to the specimen collection

B

The nurse added preservatives as per protocol and refrigerates the specimen

C

The nurse ask the client to urinate at 9:00 A.M, Friday and she included the urine in the 24 hour urine specimen

D

The nurse discards the Friday 9:00 A M urine of the client

Question 13

A framework for health assessment that evaluates the effects of stressors to the mind, body and environment in relation with the ability of the client to perform ADL.

A

Body system framework

B

Head to toe framework

C

Functional health framework

D

Cephalocaudal framework

Question 14

Nurse Angela, observe Joel who is very apprehensive over the impending operation. The client is experiencing dyspnea, diaphoresis and asks lots of questions. Angela made a diagnosis of ANXIETY R/T INTRUSIVE PROCEDURE. This is what type of Nursing Diagnosis?

A

Probable

B

Actual

C

Risk

D

Possible

Question 15

John has a fever of 39.5 degrees 2 days ago, But yesterday, he has a normal temperature of 36.5 degrees. Today, his temperature surges to 40 degrees. What type of fever is John having?

A

Relapsing

B

Intermittent

C

Constant

D

Remittent

Question 16

The American Nurses association formulated an innovation of the Nursing process. Today, how many distinct steps are there in the nursing process?

A

APIE – 4

B

ADPIE – 5

C

ADOPIE – 6

D

ADOPIER – 7

Question 17

Which of the following is TRUE about the mechanism of action of the Aortic and Carotid bodies?

A

If the BP is elevated, the RR decreases

B

Low BP leads to Metabolic acidosis

C

If the BP is elevated, the RR increases

D

Elevated BP leads to Metabolic alkalosis

Question 18

The heat regulating center is found in the

A

Hypothalamus

B

Thalamus

C

Medulla oblongata

D

Pons

Question 19

In assessing the abdomen, Which of the following is the correct sequence of the physical assessment?

A

Palpation, Auscultation, Percussion, Inspection

B

Inspection, Auscultation, Palpation, Percussion

C

Inspection, Auscultation, Percussion, Palpation

D

Inspection, Palpation, Auscultation, Percussion

Question 20

Considered as Safest and most non invasive method of temperature taking

A

Tympanic

B

Axillary

C

Oral

D

Rectal

Question 21

Which of the following completely describes PULSUS PARADOXICUS?

A

A greater-than-normal decrease in systolic blood pressure with inspiration

B

Pulse is paradoxically high when client is in standing position and low when supine.

C

Pulse is paradoxically low when client is in standing position and high when supine.

D

A greater-than-normal increase in systolic blood pressure with inspiration

Question 22

Nurse Angela knew that Stephen Lee Mu Chin, has just undergone an operation with an incision near the diaphragm. She knew that this will contribute to some complications later on. She then should develop what type of Nursing diagnosis?

A

Risk

B

Actual

C

Probable

D

Possible

Question 23

Which of the following is NOT a contraindication in taking ORAL temperature?

A

Presence of NGT

B

Nausea and Vomitting

C

Dyspnea

D

Quadriplegic

Question 24

Marianne is now at the Defervescence stage of the fever, which of the following is expected?

A

Goose flesh

B

Delirium

C

Cyanotic nail beds

D

Sweating

Question 25

Which is a preferable arm for BP taking?

A

The left arm

B

The right arm

C

An arm with the most contraptions

D

The left arm of the client with a CVA affecting the right brain

Question 26

This specimen is required to assess glucose levels and for the presence of albumin the the urine

A

24 hours urine collection

B

Postprandial urine collection

C

Midstream clean catch urine

D

Second voided urine

Question 27

Which of the following is a correct nursing action when collecting urine specimen from a client with an Indwelling catheter?

A

Insert the syringe straight to the port to allow self sealing of the port

B

Collect urine specimen from the drainage bag

C

Use sterile syringe to aspirate urine specimen from the drainage port

D

Detach catheter from the connecting tube and draw the specimen from the port

Question 28

Rhina, who has Menieres disease, said that her environment is moving. Which of the following is a valid assessment?

Rhina is giving an objective data

Rhina is giving a subjective data

The source of the data is primary

The source of the data is secondary

A

1,3

B

2,3

C

1,4

D

2.4

Question 29

Which of the following is TRUE about temperature?

A

The lowest temperature is usually in the Afternoon, Around 12 P.M

B

Thyroxin decreases body temperature

C

Elderly people are risk for hyperthermia due to the absence of fats, Decreased thermoregulatory control and sedentary lifestyle.

D

The highest temperature usually occurs later in a day, around 8 P.M to 12 M.N

Question 30

Which of the following do not correctly correlates the increase BP of Ms. Aida, a 70 year old diabetic?

A

Females, after the age 65 tends to have lower BP than males

B

Africans, have a greater risk of hypertension than Caucasian and Asians.

C

BP is highest in the morning, and lowest during the night

D

Disease process like Diabetes increase BP

Question 31

When should the client test his blood sugar levels for greater accuracy?

A

During meals

B

Before meals

C

In between meals

D

2 Hours after meals

Question 32

Which of the following is TRUE about the blood pressure determinants?

A

HCT of 70% might decrease or increase BP

B

Epinephrine decreases BP

C

Hypervolemia increases GFR

D

Hypervolemia lowers BP

Question 33

The characteristic fever in Dengue Virus is characterized as:

A

Biphasic

B

Tricyclic

C

Bicyclic

D

Triphasic

Question 34

In inspecting the abdomen, which of the following is NOT DONE?

A

The best position in assessing the abdomen is Dorsal recumbent

B

Knees and legs are straighten to relax the abdomen

C

The knees and legs are externally rotated

D

Ask the client to void first

Question 35

If the client is female, and the doctor is a male and the patient is about to undergo a vaginal and cervical examination, why is it necessary to have a female nurse in attendance?

A

To assess the client’s response to examination

B

To ensure that the doctor performs the procedure safely

C

To ensure that the procedure is done in an ethical manner

D

To assist the doctor

Question 36

They are the first one to suggest a 4 step nursing process which are : APIE , or assessment, planning, implementation and evaluation.

Yura

Walsh

Roy

Knowles

A

3,4

B

1,2

C

2,3

D

1,3

Question 37

A type of heat loss that occurs when the heat is dissipated by air current

A

Convection

B

Evaporation

C

Conduction

D

Radiation

Question 38

Among the following statements, which should be given the HIGHEST priority?

A

Client is cyanotic

B

Client is in extreme pain

C

Client’s temperature is 40 deg. Centigrade

D

Client’s blood pressure is 60/40

Question 39

Measure the leg circumference of a client with bipedal edema is best done in what position?

A

Supine

B

Dorsal recumbent

C

Standing

D

Sitting

Question 40

In assessing the client’s chest, which position best show chest expansion as well as its movements?

A

Sidelying

B

Sitting

C

Supine

D

Prone

Question 41

What can you expect from Marianne, who is currently at the ONSET stage of fever?

A

Increase thirst

B

Hot, flushed skin

C

Convulsion

D

Pale,cold skin

Question 42

Which of the following is INCORRECT in assessing client’s BP?

A

If the BP is taken on the left leg using the popliteal artery pressure, a BP of 160/80 is normal.

B

Inflate and deflate slowly, 2-3 mmHg at a time

C

Read the mercury at the upper meniscus, preferably at the eye level to prevent error of parallax

D

The sound heard during taking BP is known as KOROTKOFF sound

Question 43

The following are correct actions when taking radial pulse except:

A

Assess the pulse rate, rhythm, volume and bilateral quality

B

Use two or three fingers to palpate the pulse at the inner wrist

C

Put the palms downward

D

Use the thumb to palpate the artery

Question 44

The primary factor responsible for body heat production is the

A

Stress

B

Muscle activity

C

Metabolism

D

Release of thyroxin

Question 45

Nurse Angela is about to make a diagnosis but very unsure because the S/S the client is experiencing is not specific with her diagnosis of POWERLESSNESS R/T DIFFICULTY ACCEPTING LOSS OF LOVED ONE. She then focus on gathering data to refute or prove her diagnosis but her plans and interventions are already ongoing for the diagnosis. Which type of Diagnosis is this?

A

Probable

B

Risk

C

Possible

D

Actual

Question 46

In a routine sputum analysis, Which of the following indicates proper nursing action before sputum collection?

A

Rinse the client’s mouth with Listerine after collection

B

Discard the container if the outside becomes contaminated with the sputum

C

Tell the client that 4 tablespoon of sputum is needed for each specimen for a routine sputum analysis

D

Secure a clean container

Question 47

When palpating the client’s neck for lymphadenopathy, where should the nurse position himself?

A

At the client’s back

B

At the client’s left side

C

In front of a sitting client

D

At the client’s right side

Question 48

Which of the following is a primary factor that affects the BP?

A

Gender

B

Obesity

C

Stress

D

Age

Question 49

How long should the thermometer stay in the Client’s Axilla?

A

4 minutes

B

3 minutes

C

10 minutes

D

7 minutes

Question 50

Refers to the pressure when the ventricles are at rest

A

Systole

B

Preload

C

Pulse pressure

D

Diastole

Question 51

Clinitest is used in testing the urine of a client for glucose. Which of the following, If committed by a nurse indicates error?

A

She added 5 drops of urine and 10 drops of water

B

She added 5 drops of urine and 10 drops of water

C

The nurse puts 1 clinitest tablet into a test tube

D

Specimen is collected after meals

Question 52

A characteristic of the nursing process that is essential to promote client satisfaction and progress. The care should also be relevant with the client’s needs.

A

Humanistic

B

Effective

C

Organized and Systematic

D

Efficient

Question 53

Hyperpyrexia is a condition in which the temperature is greater than

A

40 degree Celsius

B

105.8 degree Fahrenheit

C

100 degree Fahrenheit

D

39 degree Celsius

Question 54

Contains the pneumotaxic and the apneutic centers

A

Aortic bodies

B

Medulla oblongata

C

Carotid bodies

D

Pons

Question 55

In collecting a routine specimen for fecalysis, Which of the following, if done by a nurse, indicates inadequate knowledge and skills about the procedure?

A

The nurse scoop the specimen specifically at the site with blood and mucus

B

Ask the client to defecate in a bedpan, Secure a sterile container

C

She took around 1 inch of specimen or a teaspoonful

D

Ask the client to call her for the specimen after the client wiped off his anus with a tissue

Question 56

A patient’s chart is what type of data source?

A

Secondary

B

Tertiary

C

Primary

D

Can be A and B

Question 57

Client has undergone Upper GI and Lower GI series. Which type of health assessment framework is used in this situation?

A

Head to toe framework

B

Functional health framework

C

Cephalocaudal framework

D

Body system framework

Question 58

Which characteristic of nursing process is responsible for proper utilization of human resources, time and cost resources?

A

Efficient

B

Humanistic

C

Effective

D

Organized and Systematic

Question 59

A process of heat loss which involves the transfer of heat from one surface to another is

A

Convection

B

Radiation

C

Evaporation

D

Conduction

Question 60

Which of the following statement is TRUE about pulse?

A

Males have higher pulse rate than females after puberty

B

Digitalis has a positive chronotropic effect

C

Young person have higher pulse than older persons

D

In lying position, Pulse rate is higher

Question 61

Which of the following statement is true regarding temperature?

A

The older the person, the higher his BMR

B

When the client is swimming, BMR Decreases

C

Oral temperature is more accurate than rectal temperature

D

The bulb used in Rectal temperature reading is pear shaped or round

Question 62

Rectal examination is done with a client in what position?

A

Sims position

B

Supine

C

Dorsal recumbent

D

Lithotomy

Question 63

Which of the following is the correct interpretation of the ERROR OF PARALLAX

A

If the eye level is higher than the level of the meniscus, it will cause a false high reading

B

If the eye level is higher than the level of the meniscus, it will cause a false low reading

C

If the eye level is equal to that of the level of the upper meniscus, the reading is accurate

D

If the eye level is lower than the level of the meniscus, it will cause a false low reading

Question 64

Which of the following is a contraindication in taking RECTAL temperature?

A

NPO

B

Unconscious

C

Very young children

D

Neutropenic

Question 65

Too narrow cuff will cause what change in the Client’s BP?

A

False high reading

B

True high reading

C

True low reading

D

False low reading

Question 66

A community health nurse should be resourceful and meet the needs of the client. A villager ask him, Can you test my urine for glucose? Which of the following technique allows the nurse to test a client’s urine for glucose without the need for intricate instruments.

A

Benedict’s test

B

Nitrazine paper test

C

Litmus paper test

D

Acetic Acid test

Question 67

Dr. Fabian De Las Santas, is about to conduct an ophthalmoscope examination. Which of the following, if done by a nurse, is a Correct preparation before the procedure?

A

Pour warm water over the ophthalmoscope to ensure comfort

B

Provide the necessary draping to ensure privacy

C

Open the windows, curtains and light to allow better illumination

D

Darken the room to provide better illumination

Question 68

When John has been given paracetamol, his fever was brought down dramatically from 40 degrees Celsius to 36.7 degrees in a matter of 10 minutes. The nurse would assess this event as:

A

The desired goal has been partially met

B

The goal of reducing john’s fever has been met with full satisfaction of the outcome criteria

C

The goal is not completely met

D

The goal has been met but not with the desired outcome criteria

Question 69

Which of the following is responsible for the rhythm and quality of breathing?

A

Pons

B

Carotid bodies

C

Aortic bodies

D

Medulla oblongata

Question 70

The difference between the systolic and diastolic pressure is termed as

A

Pulse deficit

B

Cardiac rate

C

Pulse pressure

D

Apical rate

Question 71

How many minutes are allowed to pass if the client had engaged in strenuous activities, smoked or ingested caffeine before taking his/her BP?

A

15

B

30

C

5

D

10

Question 72

In cleaning the thermometer after use, The direction of the cleaning to follow Medical Asepsis is :

A

From bulb to bulb

B

From stem to stem

C

From stem to bulb

D

From bulb to stem

Question 73

How long should the Rectal Thermometer be inserted to the clients anus?

A

3 to 5 inches

B

2 to 3 inches

C

.5 to 1.5 inches

D

1 to 2 inches

Question 74

Which of the following is true about the NURSING CARE PLAN?

A

At least 2 goals are needed for every nursing diagnosis

B

Verbal

C

Rationales are supported by interventions

D

It is nursing centered

Question 75

John has a fever of 38.5 Deg. Celsius. It surges at around 40 Degrees and go back to 38.5 degrees 6 times today in a typical pattern. What kind of fever is John having?

A

Constant

B

Intermittent

C

Relapsing

D

Remittent

Question 76

John’s temperature 10 hours ago is a normal 36.5 degrees. 4 hours ago, He has a fever with a temperature of 38.9 Degrees. Right now, his temperature is back to normal. Which of the following best describe the fever john is having?

A

Constant

B

Relapsing

C

Intermittent

D

Remittent

Question 77

Nurse Angela diagnosed Mrs. Delgado, who have undergone a BKA. Her diagnosis is SELF ESTEEM DISTURBANCE R/T CHANGE IN BODY IMAGE. Although the client has not yet seen her lost leg, Angela already anticipated the diagnosis. This is what type of Diagnosis?

A

Risk

B

Possible

C

Actual

D

Probable

Question 78

Which of the following is among an ideal way of collecting a urine specimen for culture and sensitivity?

A

Discard the first flow of urine to ensure that the urine is not contaminated

B

Add preservatives, refrigerate the specimen or add ice according to the agency’s protocol

C

Collect around 30-50 ml of urine

D

Use a clean container

Question 79

A community health nurse is assessing client’s urine using the Acetic Acid solution. Which of the following, if done by a nurse, indicates lack of correct knowledge with the procedure?

A

The nurse heats the test tube after adding 2/3 part of Urine

B

The nurse added the Urine as the 2/3 part of the solution

C

The nurse heats the test tube after adding 1/3 part acetic acid

D

The nurse determines abnormal result if she noticed that the test tube becomes cloudy

Question 80

The best position for any procedure that involves vaginal and cervical examination is

A

Side lying

B

Dorsal recumbent

C

Supine

D

Lithotomy

Question 81

David, 68 year old male client is scheduled for Serum Lipid analysis. Which of the following health teaching is important to ensure accurate reading?

A

Tell the patient to eat fatty meals 3 days prior to the procedure

B

NPO for 12 hours pre procedure

C

Ask the client to drink 1 glass of water 1 hour prior to the procedure

D

Tell the client that the normal serum lipase level is 50 to 140 U/L

Question 82

Which of the following is TRUE about the auscultation of blood pressure?

A

Pulse +1 is considered as NORMAL

B

Sound produced by BP is considered as HIGH frequency sound

C

The bell of the stethoscope is use in auscultating BP

D

Pulse + 4 is considered as FULL

Question 83

The sequence in examining the quadrants of the abdomen is:

A

RLQ,RUQ,LLQ,LUQ

B

RUQ,RLQ,LUQ,LLQ

C

RLQ,RUQ,LUQ,LLQ

D

RUQ,RLQ,LLQ,LUQ

Question 84

Which of the following is more life threatening?

A

BP = 160/120

B

BP = 80/50

C

BP = 180/100

D

BP = 90/60

Question 85

Which of the following need is given a higher priority among others?

A

The client is thirsty and dehydrated

B

The client has disturbance in his body image because of the recent operation

C

The client is depressed because her boyfriend left her all alone

D

The client has attempted suicide and safety precaution is needed

Question 86

Which of the following Nursing diagnosis is INCORRECT?

A

Self esteem disturbance R/T Effects of surgical removal of the leg

B

Possible ineffective coping R/T Loss of loved one

C

High risk for injury R/T Absence of side rails

D

Fluid volume deficit R/T Diarrhea

Question 87

Which of the following nursing intervention is important for a client scheduled to have a Guaiac Test?

A

Do not eat read meat 12 hours before procedure

B

Avoid turnips, radish and horseradish 3 days before procedure

C

Continue iron preparation to prevent further loss of Iron

D

Encourage caffeine and dark colored foods to produce accurate results

Question 88

Who collects Blood specimen?

A

Physical therapist

B

Medical technologist

C

Physician

D

The nurse

Question 89

Which of the following is incorrect with regards to proper urine testing using Benedict’s Solution?

A

Heat around 5ml of Benedict’s solution together with the urine in a test tube

B

Add 8 to 10 drops of urine

C

If the color remains BLUE, the result is POSITIVE

D

Heat the Benedict’s solution without the urine to check if the solution is contaminated

They should answer for WHO, WHAT ACTIONS, WHAT CIRCUMSTANCES, HOW WELL and WHEN.

Question 92

Which characteristic of nursing process addresses the INDIVIDUALIZED care a client must receive?

A

Humanistic

B

Organized and Systematic

C

Effective

D

Efficient

Question 93

When does the heart receives blood from the coronary artery?

A

When the valves opens

B

When the valves closes

C

Systole

D

Diastole

Question 94

She is the first one to coin the term “NURSING PROCESS” She introduced 3 steps of nursing process which are Observation, Ministration and Validation.

A

Johnson

B

Rogers

C

Nightingale

D

Hall

Question 95

All of the following factors correctly influence respiration except one. Which of the following is incorrect?

A

Stress increases RR

B

Increase altitude, Increase RR

C

Hydrocodone decreases RR

D

Increase temperature of the environment, Increase RR

Question 96

Which of the following is responsible for deep and prolonged inspiration

A

Carotid bodies

B

Pons

C

Medulla oblongata

D

Aortic bodies

Question 97

Tympanic temperature is taken from John, A client who was brought recently into the ER due to frequent barking cough. The temperature reads 37.9 Degrees Celsius. As a nurse, you conclude that this temperature is

A

At the low end of the normal range

B

Low

C

At the high end of the normal range

D

High

Question 98

All of the following are characteristic of the Nursing process except

A

Cyclical

B

Dynamic

C

Intrapersonal

D

Universal

Question 99

Which of the following is inappropriate in collecting mid stream clean catch urine specimen for urine analysis?

A

Discard the first flow of the urine

B

Do perineal care before specimen collection

C

Collect 5 to 10 ml for urine

D

Collect early in the morning, First voided specimen

Question 100

Which of the following is a NOT a correct statement of an Outcome criteria?

A

Demonstrates proper coughing and breathing technique after a teaching session

B

Reestablishes a normal pattern of elimination

C

Discusses fears and concerns regarding the surgical procedure

D

Ambulates 30 feet with a cane before discharge

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1. She is the first one to coin the term “NURSING PROCESS” She introduced 3 steps of nursing process which are Observation, Ministration and Validation.

Nightingale

Johnson

Rogers

Hall

2. The American Nurses association formulated an innovation of the Nursing process. Today, how many distinct steps are there in the nursing process?

APIE – 4

ADPIE – 5

ADOPIE – 6

ADOPIER – 7

3. They are the first one to suggest a 4 step nursing process which are : APIE , or assessment, planning, implementation and evaluation.

Yura

Walsh

Roy

Knowles

1,2

1,3

3,4

2,3

4. Which characteristic of nursing process is responsible for proper utilization of human resources, time and cost resources?

Organized and Systematic

Humanistic

Efficient

Effective

5. Which characteristic of nursing process addresses the INDIVIDUALIZED care a client must receive?

Organized and Systematic

Humanistic

Efficient

Effective

6. A characteristic of the nursing process that is essential to promote client satisfaction and progress. The care should also be relevant with the client’s needs.

Organized and Systematic

Humanistic

Efficient

Effective

7. Rhina, who has Menieres disease, said that her environment is moving. Which of the following is a valid assessment?

Rhina is giving an objective data

Rhina is giving a subjective data

The source of the data is primary

The source of the data is secondary

1,3

2,3

2.4

1,4

8. Nurse Angela, observe Joel who is very apprehensive over the impending operation. The client is experiencing dyspnea, diaphoresis and asks lots of questions. Angela made a diagnosis of ANXIETY R/T INTRUSIVE PROCEDURE. This is what type of Nursing Diagnosis?

Actual

Probable

Possible

Risk

9. Nurse Angela diagnosed Mrs. Delgado, who have undergone a BKA. Her diagnosis is SELF ESTEEM DISTURBANCE R/T CHANGE IN BODY IMAGE. Although the client has not yet seen her lost leg, Angela already anticipated the diagnosis. This is what type of Diagnosis?

Actual

Probable

Possible

Risk

10. Nurse Angela is about to make a diagnosis but very unsure because the S/S the client is experiencing is not specific with her diagnosis of POWERLESSNESS R/T DIFFICULTY ACCEPTING LOSS OF LOVED ONE. She then focus on gathering data to refute or prove her diagnosis but her plans and interventions are already ongoing for the diagnosis. Which type of Diagnosis is this?

Actual

Probable

Possible

Risk

11. Nurse Angela knew that Stephen Lee Mu Chin, has just undergone an operation with an incision near the diaphragm. She knew that this will contribute to some complications later on. She then should develop what type of Nursing diagnosis?

Actual

Probable

Possible

Risk

12. Which of the following Nursing diagnosis is INCORRECT?

Fluid volume deficit R/T Diarrhea

High risk for injury R/T Absence of side rails

Possible ineffective coping R/T Loss of loved one

Self esteem disturbance R/T Effects of surgical removal of the leg

13. Among the following statements, which should be given the HIGHEST priority?

Client is in extreme pain

Client’s blood pressure is 60/40

Client’s temperature is 40 deg. Centigrade

Client is cyanotic

14. Which of the following need is given a higher priority among others?

The client has attempted suicide and safety precaution is needed

The client has disturbance in his body image because of the recent operation

The client is depressed because her boyfriend left her all alone

The client is thirsty and dehydrated

15. Which of the following is TRUE with regards to Client Goals?

They are specific, measurable, attainable and time bounded

They are general and broadly stated

They should answer for WHO, WHAT ACTIONS, WHAT CIRCUMSTANCES, HOW WELL and WHEN.

16. Which of the following is a NOT a correct statement of an Outcome criteria?

Ambulates 30 feet with a cane before discharge

Discusses fears and concerns regarding the surgical procedure

Demonstrates proper coughing and breathing technique after a teaching session

Reestablishes a normal pattern of elimination

17. Which of the following is a OBJECTIVE data?

Dizziness

Chest pain

Anxiety

Blue nails

18. A patient’s chart is what type of data source?

Primary

Secondary

Tertiary

Can be A and B

19. All of the following are characteristic of the Nursing process except

Dynamic

Cyclical

Universal

Intrapersonal

20. Which of the following is true about the NURSING CARE PLAN?

It is nursing centered

Rationales are supported by interventions

Verbal

Atleast 2 goals are needed for every nursing diagnosis

21. A framework for health assessment that evaluates the effects of stressors to the mind, body and environment in relation with the ability of the client to perform ADL.

Functional health framework

Head to toe framework

Body system framework

Cephalocaudal framework

22. Client has undergone Upper GI and Lower GI series. Which type of health assessment framework is used in this situation?

Functional health framework

Head to toe framework

Body system framework

Cephalocaudal framework

23. Which of the following statement is true regarding temperature?

Oral temperature is more accurate than rectal temperature

The bulb used in Rectal temperature reading is pear shaped or round

The older the person, the higher his BMR

When the client is swimming, BMR Decreases

24. A type of heat loss that occurs when the heat is dissipated by air current

Convection

Conduction

Radiation

Evaporation

25. Which of the following is TRUE about temperature?

The highest temperature usually occurs later in a day, around 8 P.M to 12 M.N

The lowest temperature is usually in the Afternoon, Around 12 P.M

Thyroxin decreases body temperature

Elderly people are risk for hyperthermia due to the absence of fats, Decreased thermoregulatory control and sedentary lifestyle.

26. Hyperpyrexia is a condition in which the temperature is greater than

40 degree Celsius

39 degree Celsius

100 degree Fahrenheit

105.8 degree Fahrenheit

27. Tympanic temperature is taken from John, A client who was brought recently into the ER due to frequent barking cough. The temperature reads 37.9 Degrees Celsius. As a nurse, you conclude that this temperature is

High

Low

At the low end of the normal range

At the high end of the normal range

28. John has a fever of 38.5 Deg. Celsius. It surges at around 40 Degrees and go back to 38.5 degrees 6 times today in a typical pattern. What kind of fever is John having?

Relapsing

Intermittent

Remittent

Constant

29. John has a fever of 39.5 degrees 2 days ago, But yesterday, he has a normal temperature of 36.5 degrees. Today, his temperature surges to 40 degrees. What type of fever is John having?

Relapsing

Intermittent

Remittent

Constant

30. John’s temperature 10 hours ago is a normal 36.5 degrees. 4 hours ago, He has a fever with a temperature of 38.9 Degrees. Right now, his temperature is back to normal. Which of the following best describe the fever john is having?

Relapsing

Intermittent

Remittent

Constant

31. The characteristic fever in Dengue Virus is characterized as:

Tricyclic

Bicyclic

Biphasic

Triphasic

32. When John has been given paracetamol, his fever was brought down dramatically from 40 degrees Celsius to 36.7 degrees in a matter of 10 minutes. The nurse would assess this event as:

The goal of reducing john’s fever has been met with full satisfaction of the outcome criteria

The desired goal has been partially met

The goal is not completely met

The goal has been met but not with the desired outcome criteria

33. What can you expect from Marianne, who is currently at the ONSET stage of fever?

Hot, flushed skin

Increase thirst

Convulsion

Pale,cold skin

34. Marianne is now at the Defervescence stage of the fever, which of the following is expected?

Delirium

Goose flesh

Cyanotic nail beds

Sweating

35. Considered as the most accessible and convenient method for temperature taking

Oral

Rectal

Tympanic

Axillary

36. Considered as Safest and most non invasive method of temperature taking

Oral

Rectal

Tympanic

Axillary

37. Which of the following is NOT a contraindication in taking ORAL temperature?

Quadriplegic

Presence of NGT

Dyspnea

Nausea and Vomitting

38. Which of the following is a contraindication in taking RECTAL temperature?

Unconscious

Neutropenic

NPO

Very young children

39. How long should the Rectal Thermometer be inserted to the clients anus?

1 to 2 inches

5 to 1.5 inches

3 to 5 inches

2 to 3 inches

40. In cleaning the thermometer after use, The direction of the cleaning to follow Medical Asepsis is :

From bulb to stem

From stem to bulb

From stem to stem

From bulb to bulb

41. How long should the thermometer stay in the Client’s Axilla?

3 minutes

4 minutes

7 minutes

10 minutes

42. Which of the following statement is TRUE about pulse?

Young person have higher pulse than older persons

Males have higher pulse rate than females after puberty

Digitalis has a positive chronotropic effect

In lying position, Pulse rate is higher

43. The following are correct actions when taking radial pulse except:

Put the palms downward

Use the thumb to palpate the artery

Use two or three fingers to palpate the pulse at the inner wrist

Assess the pulse rate, rhythm, volume and bilateral quality

44. The difference between the systolic and diastolic pressure is termed as

Apical rate

Cardiac rate

Pulse deficit

Pulse pressure

45. Which of the following completely describes PULSUS PARADOXICUS?

A greater-than-normal increase in systolic blood pressure with inspiration

A greater-than-normal decrease in systolic blood pressure with inspiration

Pulse is paradoxically low when client is in standing position and high when supine.

Pulse is paradoxically high when client is in standing position and low when supine.

46. Which of the following is TRUE about respiration?

I:E 2:1

I:E : 4:3

I:E 1:1

I:E 1:2

47. Contains the pneumotaxic and the apneutic centers

Medulla oblongata

Pons

Carotid bodies

Aortic bodies

48. Which of the following is responsible for deep and prolonged inspiration

Medulla oblongata

Pons

Carotid bodies

Aortic bodies

49. Which of the following is responsible for the rhythm and quality of breathing?

Medulla oblongata

Pons

Carotid bodies

Aortic bodies

50. The primary respiratory center

Medulla oblongata

Pons

Carotid bodies

Aortic bodies

51. Which of the following is TRUE about the mechanism of action of the Aortic and Carotid bodies?

If the BP is elevated, the RR increases

If the BP is elevated, the RR decreases

Elevated BP leads to Metabolic alkalosis

Low BP leads to Metabolic acidosis

52. All of the following factors correctly influence respiration except one. Which of the following is incorrect?

Hydrocodone decreases RR

Stress increases RR

Increase temperature of the environment, Increase RR

Increase altitude, Increase RR

53. When does the heart receives blood from the coronary artery?

Systole

Diastole

When the valves opens

When the valves closes

54. Which of the following is more life threatening?

BP = 180/100

BP = 160/120

BP = 90/60

BP = 80/50

55. Refers to the pressure when the ventricles are at rest

Diastole

Systole

Preload

Pulse pressure

56. Which of the following is TRUE about the blood pressure determinants?

Hypervolemia lowers BP

Hypervolemia increases GFR

HCT of 70% might decrease or increase BP

Epinephrine decreases BP

57. Which of the following do not correctly correlates the increase BP of Ms. Aida, a 70 year old diabetic?

Females, after the age 65 tends to have lower BP than males

Disease process like Diabetes increase BP

BP is highest in the morning, and lowest during the night

Africans, have a greater risk of hypertension than Caucasian and Asians.

58. How many minutes are allowed to pass if the client had engaged in strenuous activities, smoked or ingested caffeine before taking his/her BP?

5

10

15

30

59. Too narrow cuff will cause what change in the Client’s BP?

True high reading

True low reading

False high reading

False low reading

60. Which is a preferable arm for BP taking?

An arm with the most contraptions

The left arm of the client with a CVA affecting the right brain

The right arm

The left arm

61. Which of the following is INCORRECT in assessing client’s BP?

Read the mercury at the upper meniscus, preferably at the eye level to prevent error of parallax

Inflate and deflate slowly, 2-3 mmHg at a time

The sound heard during taking BP is known as KOROTKOFF sound

If the BP is taken on the left leg using the popliteal artery pressure, a BP of 160/80 is normal.

62. Which of the following is the correct interpretation of the ERROR OF PARALLAX

If the eye level is higher than the level of the meniscus, it will cause a false high reading

If the eye level is higher than the level of the meniscus, it will cause a false low reading

If the eye level is lower than the level of the meniscus, it will cause a false low reading

If the eye level is equal to that of the level of the upper meniscus, the reading is accurate

63. How many minute/s is/are allowed to pass before making a re-reading after the first one?

1

5

15

30

64. Which of the following is TRUE about the auscultation of blood pressure?

Pulse + 4 is considered as FULL

The bell of the stethoscope is use in auscultating BP

Sound produced by BP is considered as HIGH frequency sound

Pulse +1 is considered as NORMAL

65. In assessing the abdomen, Which of the following is the correct sequence of the physical assessment?

Inspection, Auscultation, Percussion, Palpation

Palpation, Auscultation, Percussion, Inspection

Inspection, Palpation, Auscultation, Percussion

Inspection, Auscultation, Palpation, Percussion

66. The sequence in examining the quadrants of the abdomen is:

RUQ,RLQ,LUQ,LLQ

RLQ,RUQ,LLQ,LUQ

RUQ,RLQ,LLQ,LUQ

RLQ,RUQ,LUQ,LLQ

67. In inspecting the abdomen, which of the following is NOT DONE?

Ask the client to void first

Knees and legs are straighten to relax the abdomen

The best position in assessing the abdomen is Dorsal recumbent

The knees and legs are externally rotated

68. Dr. Fabian De Las Santas, is about to conduct an ophthalmoscope examination. Which of the following, if done by a nurse, is a Correct preparation before the procedure?

Provide the necessary draping to ensure privacy

Open the windows, curtains and light to allow better illumination

Pour warm water over the ophthalmoscope to ensure comfort

Darken the room to provide better illumination

69. If the client is female, and the doctor is a male and the patient is about to undergo a vaginal and cervical examination, why is it necessary to have a female nurse in attendance?

To ensure that the doctor performs the procedure safely

To assist the doctor

To assess the client’s response to examination

To ensure that the procedure is done in an ethical manner

70. In palpating the client’s breast, Which of the following position is necessary for the patient to assume before the start of the procedure?

Supine

Dorsal recumbent

Sitting

Lithotomy

71. When is the best time to collect urine specimen for routine urinalysis and C/S?

Early morning

Later afternoon

Midnight

Before breakfast

72. Which of the following is among an ideal way of collecting a urine specimen for culture and sensitivity?

Use a clean container

Discard the first flow of urine to ensure that the urine is not contaminated

Collect around 30-50 ml of urine

Add preservatives, refrigerate the specimen or add ice according to the agency’s protocol

73. In a 24 hour urine specimen started Friday, 9:00 A.M, which of the following if done by a Nurse indicate a NEED for further procedural debriefing?

The nurse ask the client to urinate at 9:00 A.M, Friday and she included the urine in the 24 hour urine specimen

The nurse discards the Friday 9:00 A M urine of the client

The nurse included the Saturday 9:00 A.M urine of the client to the specimen collection

The nurse added preservatives as per protocol and refrigerates the specimen

74. This specimen is required to assess glucose levels and for the presence of albumin the the urine

Midstream clean catch urine

24 hours urine collection

Postprandial urine collection

Second voided urine

75. When should the client test his blood sugar levels for greater accuracy?

During meals

In between meals

Before meals

2 Hours after meals

76. In collecting a urine from a catheterized patient, Which of the following statement indicates an accurate performance of the procedure?

Clamp above the port for 30 to 60 minutes before drawing the urine from the port

Clamp below the port for 30 to 60 minutes before drawing the urine from the port

Clamp above the port for 5 to 10 minutes before drawing the urine from the port

Clamp below the port for 5 to 10 minutes before drawing the urine from the port

77. A community health nurse should be resourceful and meet the needs of the client. A villager ask him, Can you test my urine for glucose? Which of the following technique allows the nurse to test a client’s urine for glucose without the need for intricate instruments.

Acetic Acid test

Nitrazine paper test

Benedict’s test

Litmus paper test

78. A community health nurse is assessing client’s urine using the Acetic Acid solution. Which of the following, if done by a nurse, indicates lack of correct knowledge with the procedure?

The nurse added the Urine as the 2/3 part of the solution

The nurse heats the test tube after adding 1/3 part acetic acid

The nurse heats the test tube after adding 2/3 part of Urine

The nurse determines abnormal result if she noticed that the test tube becomes cloudy

79. Which of the following is incorrect with regards to proper urine testing using Benedict’s Solution?

Heat around 5ml of Benedict’s solution together with the urine in a test tube

Add 8 to 10 drops of urine

Heat the Benedict’s solution without the urine to check if the solution is contaminated

If the color remains BLUE, the result is POSITIVE

80. +++ Positive result after Benedicts test is depicted by what color?

Blue

Green

Yellow

Orange

81. Clinitest is used in testing the urine of a client for glucose. Which of the following, If committed by a nurse indicates error?

Specimen is collected after meals

The nurse puts 1 clinitest tablet into a test tube

She added 5 drops of urine and 10 drops of water

If the color becomes orange or red, It is considered postitive

82. Which of the following nursing intervention is important for a client scheduled to have a Guaiac Test?

Avoid turnips, radish and horseradish 3 days before procedure

Continue iron preparation to prevent further loss of Iron

Do not eat read meat 12 hours before procedure

Encourage caffeine and dark colored foods to produce accurate results

83. In collecting a routine specimen for fecalysis, Which of the following, if done by a nurse, indicates inadequate knowledge and skills about the procedure?

The nurse scoop the specimen specifically at the site with blood and mucus

She took around 1 inch of specimen or a teaspoonful

Ask the client to call her for the specimen after the client wiped off his anus with a tissue

Ask the client to defecate in a bedpan, Secure a sterile container

84. In a routine sputum analysis, Which of the following indicates proper nursing action before sputum collection?

Secure a clean container

Discard the container if the outside becomes contaminated with the sputum

Rinse the client’s mouth with Listerine after collection

Tell the client that 4 tablespoon of sputum is needed for each specimen for a routine sputum analysis

85. Who collects Blood specimen?

The nurse

Medical technologist

Physician

Physical therapist

86. David, 68 year old male client is scheduled for Serum Lipid analysis. Which of the following health teaching is important to ensure accurate reading?

Tell the patient to eat fatty meals 3 days prior to the procedure

NPO for 12 hours pre procedure

Ask the client to drink 1 glass of water 1 hour prior to the procedure

Tell the client that the normal serum lipase level is 50 to 140 U/L

87. The primary factor responsible for body heat production is the

Metabolism

Release of thyroxin

Muscle activity

Stress

88. The heat regulating center is found in the

Medulla oblongata

Thalamus

Hypothalamus

Pons

89. A process of heat loss which involves the transfer of heat from one surface to another is

Radiation

Conduction

Convection

Evaporation

90. Which of the following is a primary factor that affects the BP?

Obesity

Age

Stress

Gender

91. The following are social data about the client except

Patient’s lifestyle

Religious practices

Family home situation

Usual health status

92. The best position for any procedure that involves vaginal and cervical examination is

Dorsal recumbent

Side lying

Supine

Lithotomy

93. Measure the leg circumference of a client with bipedal edema is best done in what position?

Dorsal recumbent

Sitting

Standing

Supine

94. In palpating the client’s abdomen, Which of the following is the best position for the client to assume?

Dorsal recumbent

Side lying

Supine

Lithotomy

95. Rectal examination is done with a client in what position?

Dorsal recumbent

Sims position

Supine

Lithotomy

96. Which of the following is a correct nursing action when collecting urine specimen from a client with an Indwelling catheter?

Collect urine specimen from the drainage bag

Detach catheter from the connecting tube and draw the specimen from the port

Use sterile syringe to aspirate urine specimen from the drainage port

Insert the syringe straight to the port to allow self sealing of the port

97. Which of the following is inappropriate in collecting mid stream clean catch urine specimen for urine analysis?

Collect early in the morning, First voided specimen

Do perineal care before specimen collection

Collect 5 to 10 ml for urine

Discard the first flow of the urine

98. When palpating the client’s neck for lymphadenopathy, where should the nurse position himself?

At the client’s back

At the client’s right side

At the client’s left side

In front of a sitting client

99. Which of the following is the best position for the client to assume if the back is to be examined by the nurse?

Standing

Sitting

Side lying

Prone

100. In assessing the client’s chest, which position best show chest expansion as well as its movements?

Sitting

Prone

Sidelying

Supine

Answers

D. Hall

C. ADOPIE – 6

A. 1,2

C. Efficient

B. Humanistic

D. Effective

B. 2,3

A. Actual

D. Risk

C. Possible

D. Risk

B. High risk for injury R/T Absence of side rails

D. Client is cyanotic

D. The client is thirsty and dehydrated

B. They are general and broadly stated

D. Reestablishes a normal pattern of elimination

D. Blue nails

B. Secondary

D. Intrapersonal

A. It is nursing centered

A. Functional health framework

C. Body system framework

B. The bulb used in Rectal temperature reading is pear shaped or round

A. Convection

A. The highest temperature usually occurs later in a day, around 8 P.M to 12 M.N

D. 105.8 degree Fahrenheit

D. At the high end of the normal range

C. Remittent

A. Relapsing

B. Intermittent

C. Biphasic

D. The goal has been met but not with the desired outcome criteria

D. Pale,cold skin

D. Sweating

A. Oral

D. Axillary

A. Quadriplegic

B. Neutropenic

B. .5 to 1.5 inches

B. From stem to bulb

C. 7 minutes

A. Young person have higher pulse than older persons

B. Use the thumb to palpate the artery

D. Pulse pressure

B. A greater-than-normal decrease in systolic blood pressure with inspiration

D. I:E 1:2

B. Pons

B. Pons

B. Pons

A. Medulla oblongata

B. If the BP is elevated, the RR decreases

C. Increase temperature of the environment, Increase RR

B. Diastole

B. BP = 160/120

A. Diastole

D. Epinephrine decreases BP

A. Females, after the age 65 tends to have lower BP than males

D. 30

C. False high reading

D. The left arm

A. Read the mercury at the upper meniscus, preferably at the eye level to prevent error of parallax

B. If the eye level is higher than the level of the meniscus, it will cause a false low reading

A. 1

B. The bell of the stethoscope is use in auscultating BP

A. Inspection, Auscultation, Percussion, Palpation

D. RLQ,RUQ,LUQ,LLQ

B. Knees and legs are straighten to relax the abdomen

D. Darken the room to provide better illumination

D. To ensure that the procedure is done in an ethical manner

A. Supine

A. Early morning

B. Discard the first flow of urine to ensure that the urine is not contaminated

A. The nurse ask the client to urinate at 9:00 A.M, Friday and she included the urine in the 24 hour urine specimen

D. Second voided urine

C. Before meals

B. Clamp below the port for 30 to 60 minutes before drawing the urine from the port

C. Benedict’s test

B. The nurse heats the test tube after adding 1/3 part acetic acid

D. If the color remains BLUE, the result is POSITIVE

D. Orange

A.Specimen is collected after meals

A. Avoid turnips, radish and horseradish 3 days before procedure

C. Ask the client to call her for the specimen after the client wiped off his anus with a tissue

C. Rinse the client’s mouth with Listerine after collection

B. Medical technologist

B. NPO for 12 hours pre procedure

A. Metabolism

C. Hypothalamus

B. Conduction

C. Stress

A. Patient’s lifestyle

D. Lithotomy

A. Dorsal recumbent

A. Dorsal recumbent

B. Sims position

C. Use sterile syringe to aspirate urine specimen from the drainage port